Q&A: Coding Kennedy ulcers
Q: I have a question about the coding of a Kennedy ulcer. I’ve heard that once an ulcer is identified as a Kennedy ulcer, it should no longer be coded as a pressure ulcer. How do you code a Kennedy ulcer? Or do you not code it at all?
A: A Kennedy terminal ulcer is a type of skin ulcer and not clinically considered the same as a pressure ulcer. They’re thought to be caused by poor tissue perfusion during the dying process, but we need more information in general. Because the skin is an organ, just like the heart or liver, it shows signs of failure as death approaches. Like all internal organs, it starts to slow down and function less efficiently. Kennedy ulcers usually develop on the sacrum. They develop rapidly in size, depth, and color with irregular borders. Often, they’re described as looking like a butterfly or being pear or horseshoe shaped. Treatment for a Kennedy ulcer and a pressure ulcer is the same, depending on the stage.
Kennedy ulcers don’t have a specific code in ICD-10-CM/PCS. Without further instruction in the code set, coders assign the default code for pressure ulcers. Once the ulcer is classified as a Kennedy terminal ulcer, however, coders can no longer code it as a pressure ulcer.
Present on admission (POA) indicators are also vital for pressure ulcer reporting. The POA indicators help determine whether or not an ulcer is a hospital acquired condition (HAC). CMS will not pay for conditions they see as avoidable (which means they do not pay for HACs). To read more about POAs and HACs, read the sidebar on p. 11 of the March/April CDI Journal.
October 1, 2016, revisions to the ICD-10-CM Official Guidelines for Coding and Reporting indicate that if a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay. The POA indicator for the first stage will be “Y” while the second POA indicator will be “N.” This could cause many issues since reporting of the second code will be considered a HAC.
CDI specialists should focus on educating providers to document the type of ulcer, specifying pressure versus non-pressure, location, and stage, and not using the term “Kennedy ulcer” as a descriptor. The physician needs to document the presence of an ulcer, but the nursing documentation can be used to determine the staging of that documented ulcer.
Editor’s Note: Sharme Brodie RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.